Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFYOFFICE USE: 1601, E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> L21, <br /> (Complete <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District for a permit to construct <br /> rand/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. i <br /> JOE ADDRESS/LOCATION 9Lz7o ._ _ ;�Jy1/� . CENSUS TRACT <br /> Owner's Name Phone <br /> r� <br /> Address ]��L�z----�P�-�_ _ �� / „��L.. City <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN -/7 RECONDITION fT DESTRUCTION f7 <br /> PUMP INSTALLATION� PUMP REPAIR/7 /7PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout. <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal. Installed 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. .......�.,_, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: /_7 State. Work Done <br /> DE& RUCTION OF-WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure . <br /> . . . f <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the .well. in.use.... The above <br /> information is true to the-best of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSPECTION. I 4 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEDBY A.45 DATE. ' <br /> 4/0 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P II AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY, DATE <br /> E H 1426 Rev. 1-74 2M <br />